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BACKGROUND:
Congenital talipes equinovarus (CTEV), which is also known as clubfoot, is a common congenital orthopaedic condition. It is characterised by an excessively turned in foot (equinovarus) and high medial longitudinal arch (cavus). If left untreated it can result in long-term disability, deformity and pain. Interventions can be conservative (such as splinting or stretching) or surgical.

OBJECTIVES:
To evaluate the effectiveness of interventions for CTEV.

SEARCH METHODS:
We searched CENTRAL (2011, Issue 2), NHSEED (2011, Issue 2), MEDLINE (January 1966 to April 2011), EMBASE (January 1980 to April 2011), CINAHL Plus (January 1937 to April 2011), AMED (1985 to April 2011) and the Physiotherapy Evidence Database (PEDro to April 2011). We checked the references of included studies.

SELECTION CRITERIA:
Randomised and quasi-randomised controlled trials evaluating interventions for CTEV. Participants were people of all ages with CTEV of either one or both feet.

DATA COLLECTION AND ANALYSIS:
Two authors independently assessed risk of bias in included trials and extracted the data. We contacted authors of included trials for missing information. We collected adverse event information from trials when it was available.

MAIN RESULTS:
We identified 13 trials in which there were 507 participants. The use of different outcome measures prevented pooling of data for meta-analysis even when interventions and participants were comparable. All trials displayed bias in four or more areas. One trial reported on the primary outcome of function, though raw data were not available to be analysed. We were able to analyse data on foot alignment (Pirani score), a secondary outcome, from three trials. The Pirani score is scored from zero to six, in which higher is worse. Two of the trials involved participants at initial presentation. One of them reported that the Ponseti technique significantly improved foot alignment compared to the Kite technique. After 10 weeks of serial casting, the average total Pirani score of the Ponseti group was 1.15 (95% confidence interval 0.98 to 1.32) lower than that of the Kite group. The second trial found the Ponseti technique to be superior to a traditional technique, with average total Pirani scores of the Ponseti participants 1.50 lower (95% confidence interval 0.72 to 2.28) after serial casting and Achilles tenotomy. A trial in which the type of presentation was not reported found no difference between an accelerated Ponseti or standard Ponseti treatment. At the end of serial casting, the average total Pirani scores in the standard group were 0.31 lower (95% confidence interval -0.40 to 1.02) than the accelerated group. Adverse events were not compared in the trial. There is a lack of evidence for different plaster casting products or the addition of botulinum toxin A during the Ponseti technique. There is also a lack of evidence for different types of major foot surgery for CTEV, continuous passive motion treatment following major foot surgery, or treatment of relapsed or neglected cases of CTEV. Most trials did not report on adverse events. In trials evaluating serial casting techniques, adverse events included cast slippage (needing replacement), plaster sores (pressure areas) and skin irritation. Adverse events following surgical procedures included infection and the need for skin grafting.

AUTHORS' CONCLUSIONS:
From the limited evidence available, the Ponseti technique may produce better short-term outcomes compared to the Kite technique. An accelerated Ponseti technique may be as effective as a standard technique. We could draw no conclusions from other included trials because of the limited use of validated outcome measures and lack of available raw data. Future randomised controlled trials should address these issues.

PURPOSE:
To evaluate the efficacy of a modified Copenhagen physical therapy method in reducing surgery rates for congenital idiopathic clubfoot.

METHODS:
This research is a retrospective descriptive study of 82 patients (123 clubfeet). All patients were younger than 2 months at the beginning of the treatment and were initially evaluated to classify clubfoot severity using the Harrold and Walker scale. The study period included the years from 1980 to 2003, with an average monitoring of 14.5 years (range, 3-26 years).

RESULTS:
After 3 years of treatment, 55% of the involved feet did not need surgery, 2% needed percutaneous tenotomy of the Achilles tendon, and 43% had posterior release. At the end of monitoring, 34% feet did not need surgery, 2% had percutaneous tenotomy of the Achilles tendon, and 64% required posterior releases.

CONCLUSION:
The Copenhagen method may reduce the necessity of surgical intervention for idiopathic clubfoot.

BACKGROUND:
: Residual clubfoot deformities in older children are a difficult surgical problem. The foot is stiff and almost always has already undergone some surgical intervention. The traditional approach includes soft-tissue release or osteotomy and external fixation (usually with an Ilizarov frame).

METHODS:
: In this study, we summarized our experience with the treatment of residual clubfoot deformities in older children using a percutaneous midfoot Gigli saw osteotomy and the Taylor spatial frame. There were 11 children in the study, with a mean age of 14.7 years, and mean frame fixation time was 15.1 weeks. Because the primary problems in these children were midfoot and forefoot deformities (forefoot adduction, supination, and cavus), a Butt frame was applied after the midfoot osteotomy.

RESULTS:
: At the time of frame removal, the goal of deformity correction was achieved in all the children. Two patients had partial recurrence of the deformities and were reoperated. One patient with residual supination is planned to be operated close to maturity. Complications included superficial pin-tract infection in 5 patients and premature consolidation of the osteotomy that needed reosteotomy.

CONCLUSIONS:
: On the basis of our experience, we believe that midfoot osteotomy and correction by Taylor spatial frame is an effective and reliable surgical option for this challenging problem.

OBJECTIVE:
The Mitchell-Ponseti (MP) foot abduction orthosis was introduced to provide a more user-friendly alternative to the traditional Denis-Browne (DB) brace in the treatment of idiopathic clubfoot. We describe our experience with the effectiveness of the MP brace to maintain correction of clubfeet corrected using the Ponseti method.

METHODS:
We evaluated 57 consecutive infants with 84 idiopathic clubfeet who were treated using the Ponseti method. After initial correction of the deformity was obtained, all infants were placed in the MP brace.

RESULTS:
The patients were followed for a minimum of 2 years (mean, 37.9 mo; range, 24 to 56 mo). Seventy-nine feet (94%) had heel-cord tenotomy or lengthening. The families of 34 (60%) patients were adherent with the postcorrective brace protocol. Skin problems were observed in 8 patients (14%), 6 of which were superficial dorsal skin abrasion, and none of the sandals required customization by an orthotist. A recurrence occurred in 40 feet (48%). Correction was regained with manipulation and cast application in all cases. Nineteen feet (23%) in 14 patients have had, or are scheduled for, an anterior tibial tendon transfer. At latest follow-up, all feet were plantigrade and had at least 10 degrees of dorsiflexion. None of the patients required surgical releases. Of 31 patients followed for at least 3 years, 26 (84%) used the brace for a minimum of 3 years.

CONCLUSIONS:
Using the MP foot abduction orthosis, we were able to achieve compliance rates that were at least comparable with those of earlier reports using the DB brace. Families found the brace easy to use. The MP brace may be considered a useful alternative to the DB brace.

Background: Two main options for treatment of congenital idiopathic clubfoot are the “French” functional method and the Ponseti method. The goal of this article was to evaluate the results of the functional treatment method, which, if necessary, is completed by a surgical release.

Patients and Methods: A series of 187 feet (129 patients) underwent functional conservative treatment. At first evaluation, the feet were classified according to the classification of Dimeglio. All patients then underwent daily physiotherapy and splintage, which was progressively stopped during childhood. Among these 187 feet, 85 feet (45.5%) required soft-tissue release to correct the remaining deformity. Surgery, when required, consisted of a complete posterolateral and medial release procedure, combined with a lengthening of the tibialis anterior tendon in most cases and a bony lateral procedure in case of forefoot adduction.

Results: At the latest follow-up (14.7 y; range, 7.4 to 23 y), results were “good” or “very good” in almost 98% of feet, according to the Ghanem and Seringe score. Severe feet at first consultation showed a worse result and required surgery more often than did the less severe ones. Among nonoperated feet, very good results were found in 99% of feet, and none had a fair or bad result. The average age at surgery was 2.5 years. Feet operated upon had lower results compared with the others. At last follow-up, among the operated feet, the results were excellent or good in 95% of the feet. The results were fair or bad in 4 cases; all 4 feet had been operated upon more than once. The results were not statistically dependent on age at the time of surgery, but feet operated upon before the age of 2 years had statistically more flattening of the talar dome and subtalar stiffness.

Conclusions: The functional treatment of clubfoot leads to a very good result without the need for surgery in more than half of the patients. The initial severity of the feet is the main factor that influences the final result. The rate of feet not requiring surgery should be increased by recent modifications to the method, including percutaneous Achilles tenotomy.

Clubfoot (talipes equinovarus) is a three-dimensional deformity of unknown etiology. Treatment aims at correction to obtain a functional, plantigrade pain-free foot. The "French" functional method involves specialized physiotherapists. Daily manipulation is associated to immobilization by adhesive bandages and pads. There are basically three approaches: the Saint-Vincent-de-Paul, the Robert-Debré and the Montpellier method. In the Ponseti method, on the other hand, the reduction phase using weekly casts usually ends with percutaneous tenotomy of the Achilles tendon to correct the equinus. Twenty-four hour then nighttime splinting in abduction is then maintained for a period of 3 to 4 years. Recurrence, mainly due to non-compliance with splinting, is usually managed by cast and/or anterior tibialis transfer. The good long-term results, with tolerance of some anatomical imperfections, in contrast with the poor results of extensive surgical release, have led to a change in clubfoot management, in favor of such minimally invasive attitudes. The functional and the Ponseti methods reported similar medium term results, but on scores that were not strictly comparable. A comparative clinical and 3D gait analysis with short follow-up found no real benefit with the increasingly frequent association of Achilles lengthening to the functional method (95% to 100% initial correction). Some authors actually suggest combining the functional and Ponseti techniques. The Ponseti method seems to have a slight advantage in severe clubfoot; if it is not properly performed, however, the risk of failure or recurrence may be greater. "Health economics" may prove decisive in the choice of therapy after cost-benefit study of each of these treatments.

The Ponseti and French taping methods have reduced the incidence of major surgery in congenital idiopathic clubfoot but incur a significant burden of care, including heel-cord tenotomy. We developed a non-operative regime to reduce treatment intensity without affecting outcome. We treated 402 primary idiopathic clubfeet in patients aged < three months who presented between September 1991 and August 2008. Their Harrold and Walker grades were 6.0% mild, 25.6% moderate and 68.4% severe. All underwent a dynamic outpatient taping regime over five weeks based on Ponseti manipulation, modified Jones strapping and home exercises. Feet with residual equinus (six feet, 1.5%) or relapse within six months (83 feet, 20.9%) underwent one to three additional tapings. Correction was maintained with below-knee splints, exercises and shoes. The clinical outcome at three years of age (385 feet, 95.8% follow-up) showed that taping alone corrected 357 feet (92.7%, ‘good’). Late relapses or failure of taping required limited posterior release in 20 feet (5.2%, ‘fair’) or posteromedial release in eight feet (2.1%, ‘poor’). The long-term (> 10 years) outcomes in 44 feet (23.8% follow-up) were assessed by the Laaveg–Ponseti method as excellent (23 feet, 52.3%), good (17 feet, 38.6%), fair (three feet, 6.8%) or poor (one foot, 2.3%). These compare favourably with published long-term results of the Ponseti or French methods. This dynamic taping regime is a simple non-operative method that delivers improved medium-term and promising long-term results.

Background
Idiopathic congenital talipes equinovarus (CTEV) is the commonest form of clubfoot. Its exact cause is unknown, although it is related to limb development. The aim of this study was to quantify the anatomy of the muscle, subcutaneous fat, tibia, fibula and arteries in the lower legs of teenagers and young adults with CTEV using 3D magnetic resonance imaging (MRI), and thus to investigate the anatomical differences between CTEV participants and controls.

Methodology/Principal Findings
The lower legs of six CTEV (2 bilateral, 4 unilateral) and five control young adults (age 12–28) were imaged using a 3T MRI Philips scanner. 5 of the CTEV participants had undergone soft-tissue and capsular release surgery. 3D T1-weighted and 3D magnetic resonance angiography (MRA) images were acquired. Segmentation software was used for volumetric, anatomical and image analysis. Kolmogorov-Smirnov tests were performed. The volumes of the lower affected leg, muscle, tibia and fibula in unilateral CTEV participants were consistently smaller compared to their contralateral unaffected leg, this was most pronounced in muscle. The proportion of muscle in affected CTEV legs was significantly reduced compared with control and unaffected CTEV legs, whilst proportion of muscular fat increased. No spatial abnormalities in the location or branching of arteries were detected, but hypoplastic anomalies were observed.

Conclusions/Significance
Combining 3D MRI and MRA is effective for quantitatively characterizing CTEV anatomy. Reduction in leg muscle volume appears to be a sensitive marker. Since 5/6 CTEV cases had soft-tissue surgery, further work is required to confirm that the treatment did not affect the MRI features observed. We propose that the proportion of muscle and intra-muscular fat within the lower leg could provide a valuable addition to current clinical CTEV classification. These measures could be useful for clinical care and guiding treatment pathways, as well as treatment research and clinical audit.

Congenital talipes equinovarus (clubfoot) is a complex deformity of the lower extremity and foot occurring in 1/1000 live births. Regardless of treatment, whether conservative or surgical, clubfoot has a stubborn tendency to relapse, thus requiring postcorrection bracing. However, to date, there are no investigations specifically focused on clubfoot bracing from a bioengineering perspective. This study applied engineering principles to clubfoot bracing through construction of a surrogate biomodel. The surrogate was developed to represent an average 5-year-old human subject capable of biomechanical characteristics including joint articulation and kinematics. The components include skeleton, articulating joints, muscle-tendon systems, and ligaments. A protocol was developed to measure muscle-tendon tension in resting and braced positions of the surrogate. Measurement error ranged from 1% to 6% and was considered variance due to brace and investigator. In conclusion, this study shows that surrogate biomodeling is an accurate and repeatable method to investigate clubfoot bracing. The methodology is an effective means to evaluate wide ranging brace options and can be used to assist in future brace development and the tuning of brace parameters. Such patient-specific brace tuning may also lead to advanced braces that increase compliance.

Congenital clubfoot is a common congenital deformity, characterized by equinus of the hindfoot and adduction of the midfoot and forefoot, with varus through the subtalar joint complex. A cavus deformity will also be present. The etiology of this congenital deformity remains elusive. Muscle anomalies are not commonly found in patients with idiopathic clubfoot, and, when present, their significance is not clear. The presence of a flexor digitorum accessorius longus muscle and an accessory soleus muscle found at surgical correction of clubfoot deformity has been previously reported. Our case was a female child, aged 2 years, 3 months, who developed bilateral relapsed congenital clubfoot. She was found to have an unusual aberrant muscle in both legs. This was discovered accidentally during surgical correction of her deformity through posteromedial soft tissue release. This muscle might have contributed to the hindfoot varus and equinus in the clubfoot deformity, because the latter were completely corrected after release of the muscle from its insertion. Awareness of such a new anatomic variant, with the other anatomic variants found in clubfoot deformity, will not only improve our understanding of normal lower limb development, but could also lead to improved genetic counseling and diagnostic and treatment methods of such a common congenital deformity.

BACKGROUND:
Neglected clubfoot in older children is characterized by a stiff, nonreducible deformity with relative elongation of the lateral column of the foot with respect to the medial column. Surgical correction often has involved a double osteotomy with elongation of the medial column and shortening of the lateral column, or the use of an external fixator to achieve more gradual correction. Both approaches have shortcomings.

QUESTIONS/PURPOSES:
We therefore (1) used objective physical examination measurements and a functional assessment to evaluate the effectiveness of cuboid osteotomy combined with a selective soft tissue release to achieve correction of neglected clubfoot in older children, (2) determined the rate of complications, and (3) ascertained whether the initial correction achieved was maintained.

RESULTS:
According to the Laaveg and Ponseti classification, 24 feet showed excellent correction, 20 good, nine fair, and three poor at 1-year followup. These results were maintained up to the latest followup. Patients showed significant improvement of Dimeglio score after surgery (p < 0.0001). Two patients had postoperative skin-related complications that healed without additional surgery.

Background: Talectomy is a common surgical procedure in the treatment of rigid, resistant talipes equinovarus deformity especially in patients with arthrogryposis and spina bifida. The aim of this study is to evaluate the indications and results of talectomy. Patients and

Methods: A retrospective review of all patients who underwent talectaomy in the period between 2004 and 2010 at King Hussein Medical Center. We reviewed the result of 48 talectomies in 31 patients with severe, rigid clubfoot. each surgery was analyzed regarding the indication and outcome .Also the description and the back ground of this procedure were included.

Results : We reviewed the result of 48 talectomies in 31 patients with severe, rigid clubfoot. The average age at the time of surgery was 3.7 years and the mean follow-up was 5 years. The aim of treatment of these patients is to provide a foot that is plantigrade, painless and can be placed within a standard footwear . 85% of our patients (41feet) who under went talectomy were arthrogrypotic, other 6 cases with spina bifida (13%), and one case for neglected, rigid idiopathic clubfoot( 2%) . Thirty-seven feet ( 77% ) were considered satisfactory, the reminder were improved, further surgeries were done in six cases, but finally all feet could be fitted with shoes and all patients could walk.

Conclusion : We conclude that talectomy is an effective procedure in severe , rigid, resistant clubfeet. The main indication is in the treatment of patients with arthrogryposis and spina bifida, also it can be used in neglected, rigid idiopathic talipes equinovarus .

Methods: Twenty children with twenty two congenital talipes equinovarus (CTEV) feet with moderate or severe degree of deformity operated between March 2010 to April 2012. Eight children 40% were female and twelve children 60% were male. Two presented with bilateral, 6 with right and 12 with left foot involvement. All the twenty-two feet were treated with extensile posteromedial and posterolateral release through Cincinnati incision.

Results: Patients were evaluated clinically. Average follow up was nine months and results were satisfactory.

BACKGROUND:
Pediatric indications for Onabotulinumtoxin A® extend beyond treatment of skeletal muscle conditions. Each of the indications for Onabotulinumtoxin A® use have adverse events reported in the past. The aim of this study was to review dverse events in children less than 2 years of age who were treated with Onabotulinumtoxin A® injections as part of equinus foot deformity, in the setting of clubfoot at British Columbia's Children Hospital.
METHODS:
A retrospective review of all clubfoot patients at British Columbia's Children Hospital, less than 2 years of age, who received a Onabotulinumtoxin A® injection for equinus correction, between September 2000 and December 2012 was conducted. Data collected included demographics, clinical diagnosis, treatment history, ankle range of motion and any adverse event noted by the clubfoot team or reported by the families.
RESULTS:
A total of 239 eligible subjects (361 feet) had received 523 Onabotulinumtoxin A® injections before the age of 2 years. There was only one adverse event reported out of the 523 Onabotulinumtoxin A® injections (adverse events rate of 0.19%) given at British Columbia's Children Hospital. However, this adverse event was not found related to the Onabotulinumtoxin A® injection.
CONCLUSIONS:
Onabotulinumtoxin A® appears to be safe with respect to the adverse events, for use in children under 2 years of age with the diagnosis of clubfoot when dosed at 10 units per kilogram. However, the dose of Onabotulinumtoxin A® and underlying diagnosis should always be kept in mind.

Congenital talipes equinovarus (CTEV) is a condition of the lower limb in which there is fixed structural cavus, forefoot adductus, hindfoot varus and ankle equinus. In Caucasian populations the incidence is around 1.2 per 1,000 live births, with a male to female ratio of 2.25:1. The left and right feet are equally commonly affected, and 50% of cases are bilateral. It is important to differentiate CTEV from a non-structural or positional talipes which is fully correctable. This positional variant occurs about five times as commonly as CTEV. The latter condition does not require casting or surgical treatment. The majority of CTEV cases are picked up at the early baby check or on prenatal ultrasound, and referred to the paediatric orthopaedic service. However, some cases are mistaken early on as the positional variant, and may therefore present to the GP e.g. at the six week check. Urgent referral is warranted as the Ponseti treatment should be started early. The feet must be examined directly to see if the components of the deformity are fixed, defining CTEV. The hips (stability, length equivalence, range and symmetry of abduction) and spine (in particular looking for peripheral stigmata of spina bifida) must also be examined. Most cases of CTEV occur in isolation i.e. without other anomalies. However, a proportion are syndromic. In a recent study of patients with fixed CTEV, 27.7% had a syndromal cause. Over the past 25 years there has been a dramatic shift away from extensive surgical releases to manipulative methods/serial casting such as the Ponseti technique. The technique involves a series of manipulations and casts, usually on a weekly basis, in which the foot is brought round to a corrected position. The boots and bar splintage is a vital part of the Ponseti technique and relapse is strongly correlated with non-compliance.

Background: Relapses following nonoperative treatment for clubfoot occur in 29% to 37% of feet after initial correction. One common gait abnormality is supination and inversion of the foot caused by an imbalance of the anterior tibialis tendon muscle. The purpose of this study was to determine if plantar pressures are normalized following an anterior tibialis tendon transfer (ATTT).

Methods: Thirty children (37 clubfeet) who underwent an ATTT, were seen for plantar pressure testing preoperatively and postoperatively. Each foot was subdivided into 7 regions: medial/lateral hindfoot and midfoot, and the forefoot (first, second, and third to fifth metatarsal heads). Variables included: contact time as a percentage of stance time (CT%), contact area as a percentage of the total foot (CA%), peak pressure (PP), hindfoot-forefoot angle (H-F), location of initial contact, and deviation of the center-of-pressure line (COP). Paired t tests were used for group comparisons, whereas multiple comparisons were assessed with ANOVA ([alpha] set to 0.05 with Bonferroni correction).

Results: Significant changes were seen in preoperative to postoperative comparison. PP, CT%, and CA% had significant increases in the medial hindfoot, midfoot, and first metatarsal regions, whereas the involvement of the lateral midfoot and forefoot were reduced. Compared with controls, postoperative results following ATTT continue to show increased PP, CA%, and CT% in the lateral midfoot, increased CA% and CT% in the lateral forefoot, whereas CA% was decreased in the first metatarsal region. Compared with controls, the COP line continues to move laterally and the H-F angle continues to show forefoot adductus following ATTT. No differences were found between patients treated with an isolated ATTT and those treated with concomitant procedures.

Conclusions: The changes seen in plantar pressures following ATTT would suggest that the foot is better aligned for a more even distribution of pressure throughout the foot, but is not fully normalized.

Dynamic supination of the foot is a common residual deformity in children with clubfeet treated with the Ponseti method. Transfer of the anterior tibialis tendon (ATT) to the lateral cuneiform is an effective method for correcting this deformity when the cuneiform is ossified in children who are 3 to 5 years of age. We describe two cases of a previously unreported method of ATT transposition for correction of bilateral residual dynamic supination in a 26-month-old and a 19-month-old patient. Both patients presented shortly after birth with bilateral congenital idiopathic clubfoot and were initially treated with the Ponseti method. Both had residual deformity following initial treatment that included posterior contracture and metatarsus adductus with dynamic forefoot supination. This was surgically corrected with a posterior release and medial release of the 1st metatarsal/1st cuneiform joint. To correct dynamic supination, the ATT was transplanted laterally into the released midfoot joint. These two patients were followed post-operatively for 7.5 years and have correction of their residual deformity in both feet based on subjective functioning, appearance, range of motion, strength, and gait. Both have excellent lateral pull of their ATT, which functions as a strong foot dorsiflexor. No residual supination is present. This is the first report of lateral transposition of the ATT as an interposition graft at the released 1st metatarsal/1st cuneiform joint in patients with relapsed clubfoot. We suggest that this method should provide a high level of functioning in children with relapsed supination deformity and whose 3rd cuneiform has not yet ossified.

BACKGROUND:
Congenital talipes equinovarus (CTEV), which is also known as clubfoot, is a common congenital orthopaedic condition characterised by an excessively turned in foot (equinovarus) and high medial longitudinal arch (cavus). If left untreated it can result in long-term disability, deformity and pain. Interventions can be conservative (such as splinting or stretching) or surgical. The review was first published in 2012 and we reviewed new searches in 2013 (update published 2014).
OBJECTIVES:
To evaluate the effectiveness of interventions for CTEV.
SEARCH METHODS:
On 29 April 2013, we searched CENTRAL (2013, Issue 3 in The Cochrane Library), MEDLINE (January 1966 to April 2013), EMBASE (January 1980 to April 2013), CINAHL Plus (January 1937 to April 2013), AMED (1985 to April 2013), and the Physiotherapy Evidence Database (PEDro to April 2013). We also searched for ongoing trials in the WHO International Clinical Trials Registry Platform (2006 to July 2013) and ClinicalTrials.gov (to November 2013). We checked the references of included studies. We searched NHSEED, DARE and HTA for information for inclusion in the Discussion.
SELECTION CRITERIA:
Randomised controlled trials (RCTs) and quasi-RCTs evaluating interventions for CTEV. Participants were people of all ages with CTEV of either one or both feet.
DATA COLLECTION AND ANALYSIS:
Two authors independently assessed risk of bias in included trials and extracted the data. We contacted authors of included trials for missing information. We collected adverse event information from trials when it was available.
MAIN RESULTS:
We identified 14 trials in which there were 607 participants; one of the trials was newly included at this 2014 update. The use of different outcome measures prevented pooling of data for meta-analysis even when interventions and participants were comparable. All trials displayed bias in four or more areas. One trial reported on the primary outcome of function, though raw data were not available to be analysed. We were able to analyse data on foot alignment (Pirani score), a secondary outcome, from three trials. Two of the trials involved participants at initial presentation. One reported that the Ponseti technique significantly improved foot alignment compared to the Kite technique. After 10 weeks of serial casting, the average total Pirani score of the Ponseti group was 1.15 (95% confidence interval (CI) 0.98 to 1.32) lower than that of the Kite group. The second trial found the Ponseti technique to be superior to a traditional technique, with average total Pirani scores of the Ponseti participants 1.50 lower (95% CI 0.72 to 2.28) after serial casting and Achilles tenotomy. A trial in which the type of presentation was not reported found no difference between an accelerated Ponseti or standard Ponseti treatment. At the end of serial casting, the average total Pirani scores in the standard group were 0.31 lower (95% CI -0.40 to 1.02) than the accelerated group. Two trials in initial cases found relapse following Ponseti treatment was more likely to be corrected with further serial casting compared to the Kite groups which more often required major surgery (risk difference 25% and 50%). There is a lack of evidence for different plaster casting products, the addition of botulinum toxin A during the Ponseti technique, different types of major foot surgery, continuous passive motion treatment following major foot surgery, or treatment of relapsed or neglected cases of CTEV. Most trials did not report on adverse events. In trials evaluating serial casting techniques, adverse events included cast slippage (needing replacement), plaster sores (pressure areas) and skin irritation. Adverse events following surgical procedures included infection and the need for skin grafting.
AUTHORS' CONCLUSIONS:
From the limited evidence available, the Ponseti technique produced significantly better short-term foot alignment compared to the Kite technique and compared to a traditional technique. The quality of this evidence was low to very low. An accelerated Ponseti technique may be as effective as a standard technique, according to moderate quality evidence. Relapse following the Kite technique more often led to major surgery compared to relapse following the Ponseti technique. We could draw no conclusions from other included trials because of the limited use of validated outcome measures and lack of available raw data. Future randomised controlled trials should address these issues.

Purpose
The “bean-shaped foot” exhibits forefoot adduction and midfoot supination, which interfere with function because of poor foot placement. The purpose of the study is a retrospective evaluation of patients who underwent a combined double tarsal wedge osteotomy and transcuneiform osteotomy to correct such a deformity.
Methods
Twenty-seven children with 35 idiopathic clubfeet were treated surgically by combined double tarsal wedge osteotomy (closing wedge cuboid osteotomy and opening wedge medial cuneiform osteotomy) and transcuneiform osteotomy between 2008 and 2012. The age of children at surgery ranged from 4 to 9 years. There were 19 boys and 8 girls. Pre- and postoperative X-rays were used, considering: on the AP radiograph, the calcaneo-fifth metatarsal angle and the talo-first metatarsal angle (indicators of forefoot adduction); on the lateral radiograph, the talo-first metatarsal angle (an indication of supination deformity) and calcaneo-first metatarsal angles (an indication of cavus deformity). These radiological parameters were compared with the clinical results.
Results
Follow-up was conducted for 24–79 months following surgery. Clinical and radiographic improvements in forefoot position were achieved in all cases. An average improvement in the anteroposterior talo-first metatarsal angle of 21°, calcaneo-fifth metatarsal angle of 14°, lateral talo-first metatarsal angle of 10°, and lateral calcaneo-first metatarsal of 12° confirmed the clinically satisfactory correction in all feet. One patient had a wound infection postoperatively, which resolved with removal of the wires and administration of oral antibiotics. Eight patients followed up for more than 5 years had no deterioration of results.
Conclusions
Combined double tarsal wedge osteotomy as well as transcuneiform osteotomy is an effective and safe procedure for lasting correction of the bean-shaped foot.

OBJECTIVE:
The aim of the present study was to determine the effectiveness of parent manipulation on newborns with postural clubfoot, as compared to newborns that receive no treatment in a randomized controlled trial.
MATERIAL AND METHOD:
Ninety-two healthy newborns, including 40 boys and 52 girls, (169 postural clubfeet, including 77 with bilaterally involvement) were included and categorized into two groups by simple randomization using the sealed opaque envelope technique. In Group A, the parent manipulation group, there were 14 boys and 33 girls in 85 postural clubfeet with 38 bilateral involvements. Manipulations were performed at least 20 times per day and the stimulation of the newborn's foot/ feet byparent finger was performed at least 100 times per day. In Group B, the group of newborns receiving no treatment, there were 26 boys and 19 girls in 84 postural clubfeet with 39 bilateral involvements. The follow-up periods for both groups were one, three, and four months after starting the manipulation. The success of the manipulation was measured by the foot appearance, which was normally performed by physical examination.
RESULTS:
A comparison of the characteristics of newborns and parents in both groups showed no statistical differences, except the sex of the newborn. All newborns in both groups were one to six days old. The success rate after 4 months of manipulation in Group A was 71.8%, but it was 81% in Group B with no manipulation; results indicate no statistically significant difference (p = 0.16). The severity of the postural clubfeet indicated no statistical difference in the results of either group (p = 0.3). All cases were followed up at one year with 14% of the studyparticipants dropping out in Group A and 11% dropping out of the study in Group B. All postural clubfeet disappeared in every case within one year of birth except one case in Group A that required casting and one case in Group B that required a prescription for orthopaedic shoes.
CONCLUSION:
No clinical or statistical differences were found between newborns who received parent manipulation for the treatment of postural clubfoot and newborns who received no treatment. Spontaneous recovery occurred in most of the cases within four months of birth or not more than one year after birth.

Although the Ponseti serial casting method is the gold standard for the management of clubfoot, surgical correction remains the best option for resistant cases. Therefore, we compared posteromedial and posteromedial-lateral surgical approaches for the correction of resistant clubfoot. Between 2007 and 2013, 68 patients with idiopathic nonsyndromic resistant clubfoot, who were admitted to our referral institute, were enrolled in our study. The patients were divided into two groups. The patients in group 1 (33 cases of clubfoot) underwent posteromedial release with a single incision and those in group 2 (35 cases of clubfoot) underwent posteromedial-lateral release by two separate incisions. The severity of deformity was classified according to the Dimeglio classification. After the operations, all patients were followed up and surgical results as well as acute and chronic complications were evaluated. The patients were followed up for a mean of 43 months, and at the last follow-up visit, the Dimeglio scores in groups 1 and 2 were 4.8±3.8 and 3.3±2.6, respectively (P=0.04). Outcomes improved in both groups significantly. Although group 2 had more severe deformity, compared with group 1 at the baseline, the final outcome was better in this group. Heel varus and equinus was corrected more appropriately in group 2. Complications such as navicular dorsal subluxation and valgus overcorrection were less common in group 2. In cases of resistant clubfoot, it appears that a posteromedial-lateral approach with two separate incisions not only provides a better correction but is also associated with a lower complication rate in comparison with the single-incision posteromedial approach

Forty-six severe clubfeet in 29 patients were treated by serial castings, followed by a newly developed dynamic splint. The mean period of splint usage was 59.9 months and the mean period of follow-up was 81.5 months. Of the patients, 76.1% were satisfied, 87.0% had no functional deficit, and 84.8% had no pain. Radiographical evaluation showed good correction. The mean dorsiflexion angle was –0.8° at the end of cast treatment and 13.6° at the time of the final follow-up. This study clearly showed the effectiveness of a functional dynamic splint for the correction of equinus in cases of severe clubfoot.

Rapid prototyping (RP) is a technique which produce 3D model of a part from the CAD model using the additive manufacturing technology. Unlike the traditional method of manufacturing, in this technique small layers are added on top of one another to form the final part. This allows rapid prototyping to create very complex parts in relatively less time period. In recent years this technique has been applied to medical field.

Common RP techniques used in the medical field are Selective Laser Sintering, Fused Deposition Modeling, Multi-Jet Modeling and Stereolithography. But for most of the above methods, the working principle remains the same. The input data for model generation is obtained from Magnetic Resonance Imaging (MRI) or Computer Tomography (CT) scan which is converted to a 3D model by image processing software. This 3D model is converted to STL format which is read by the RP machine by creating thin slices of the model.

Clubfoot, a challenging foot deformity generally occurs at birth, is caused by the abnormal posturing of the foot which becomes twisted so that the sole cannot be placed flat on the ground. The treatment for clubfoot should begin immediately, preferably in the first week of birth since the tissues, tendons, ligaments and bones of the new born's foot will yield to gentle pressure over time. The treatment involves manipulations and serial casting for correction and orthosis for maintenance.

This paper focuses on the applications of rapid prototyping in designing a corrective orthosis which will replace serial casting in the treatment of Clubfoot in children. Rapid prototyping has proven to facilitate, speed up and improve the quality of procedures and products.

Purpose
The purpose of this study is to compare the efficacy of percutaneous Achilles tenotomy (AT) to combined open Achilles tenotomy and posterior capsulotomy (PC+AT) in the correction of residual equinus deformity in congenital talipes equinovarus after Ponseti serial casting in both idiopathic and non-idiopathic clubfeet.
Methods
The authors retrospectively reviewed 591 patients treated for congenital talipes equinovarus between January 1, 2001 and January 1, 2011. Available medical and operative records were reviewed for basic demographic data as well as ankle dorsiflexion pre-operatively, postoperatively and at latest follow up.
Results
A total of 167 children with 260 discrete clubfeet that met our inclusion criteria were identified. Of them, 189/260 clubfeet (72.7 %) were idiopathic and 71/260 clubfeet (27.3 %) were non-idiopathic with a mean total follow up of 4.8 ± 2.4 years (minimum follow-up of two years). At latest follow up, there was no statistically significant difference in the mean ankle dorsiflexion (p = 0.333) or recurrence rate (p = 0.545) between PC+AT and AT groups in both idiopathic and non-idiopathic clubfeet.
Conclusion
In our series, the addition of posterior capsulotomy to Achilles tenotomy did not improve the mean dorsiflexion at latest follow up or decrease the rate of recurrence of equinus deformity in both idiopathic and non-idiopathic clubfeet. It is therefore advisable that percutaneous Achilles tenotomy alone be used in the correction of equinus deformity in both idiopathic and non-idiopathic congenital talipes equinovarus after successful Ponseti serial casting.